| NPI | 1750778742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: OK 508) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: OK 1602) |
| Enumeration Date | 2015-04-17 |
| Last Update Date | 2015-04-17 |